Introduction: Clubfoot is a common congenital deformity with incidence of one in thousand live births. Ponseti method is currently the gold standard for treatment of clubfoot which conventionally involves weekly plaster changes. A prospective comparative study was carried out at our institute where we compared one group with weekly plaster change to other group with triweekly plaster change using the classical Ponseti protocol of manipulation. Methods: A total of 40 feet, divided into two groups, were randomly allocated to either Group A – 20 feet (standard Ponseti) or Group B – 20 feet (accelerated Ponseti). Group A underwent serial manipulations and casting once a week and Group B received manipulations and castings thrice a week. Pirani score was documented at presentation, at each cast, and at the time of removal of final cast to assess the success of treatment in terms of Pirani score ≤1. Results: The average number of casts needed for correction in accelerated group was 7 (16 patients, 20 feet) and in standard group was 6.35 (15 patients, 20 feet). The mean follow-up in accelerated group was 7.84 months whereas in standard group was 6.66 months. Tendoachilles tenotomy was required in 65% feet in accelerated group and 55% in standard group. Conclusion: Both methods standard and accelerated Ponseti have proven to be equally efficacious for the management of clubfoot in our study. However, the accelerated method has a overall shorter treatment duration making it more cost effective and convenient for the parents. As patient is under direct observation of surgeons, any complications are detected early and easily. Overall, the accelerated technique is more practical, beneficial, and labor-saving for poor patients from rural part of India where recurrent visit to tertiary government care center is inconvenient and troublesome.

Clubfoot also known as congenital talipes equinovarus (CTEV) is a common birth defect that affects one in thousand live births.[1] It is characterized by adduction, varus, equinus, and cavus deformities of the foot. Clubfoot has been existent and known since time of Egyptians and similar is the duration of controversies it carries with itself. A variety of classification systems based on clinical examination have been used, the most widely used being that of Pirani[2] which has shown good interobserver reliability and reproducibility.[3] The Ponseti method has transformed the management of children with clubfoot producing good long-term results[4],[5] and in the last two decades has gained wide acceptance worldwide.[6] The last deformity to be corrected is equinus, which often requires a percutaneous tendoachilles tenotomy followed by a final plaster cast for 3 weeks. Once plaster treatment is over, feet are maintained in a foot-abduction brace. Percutaneous tendoachilles tenotomy and later tibialis anterior transfer may be used but are not always necessary.[7]

The first written record of clubfoot treatment is found in the works of Hippocrates from around 400 BC. Hippocrates was the first to advocate orthopedic treatment of clubfoot by gentle manipulation and bandaging. Nicholas Andry (1743) in his “Orthopaedia” called the deformity as pedes equinus resembling the foot of horse. The first advance in nonoperative treatment of clubfoot occurred in 1836 when Guerin introduces the plaster-of-Paris cast. In 1932, Dr. Hiram Kite, recognizing that forceful manipulation and extensive surgical releases were harmful, recommended a return to gentle manipulation and cast immobilization for the nonoperative treatment of congenital clubfoot. As the treatment modalities evolved, various surgeries were done to overcome this deformity; however, relapse as well as complications were seen and the trend started shifting toward conservative approach. Dr. Ignacio Ponseti a Spanish Physician in the 1960s, specializing in Orthopedics, devised his method of conservative treatment of CTEV which starts from day 1 of age and is based on the fundamentals of kinematics and pathoanatomy of the deformity and successfully realigns clubfoot in infants without extensive and major surgeries. High success rate of the Ponseti method has made it the most widely practiced treatment for clubfoot in modern era.[6] Classic Ponseti method involves weekly plaster change with gradual abduction of foot. In accelerated Ponseti method, the manipulation method remains the same but plaster is changed two,[8],[10] or three times[9] a week. This study was done with an aim to determine effectiveness of a shorter duration of treatment which has obvious advantages in a country like India where parents have to travel long distances to bring their children for plaster changes.

Materials and Methods

A prospective comparative study of accelerated Ponseti versus the standard Ponseti method for treatment of idiopathic clubfoot was done at our institute. The duration of the study was from September 2013 to October 2015, and the study included 31 patients (40 feet, 20 feet for each group).

Each patient registered was given a clubfoot clinic number and detailed personal history was recorded including the age, sex, name of parents, laterality, address, date of first reporting, age at reporting, and detailed history of any previous treatment. A Club Foot Clinic card containing all the required information was issued and pamphlets containing all the required information in the local language were given to attendants. The patients were followed up regularly at the clinic and assessed.

Children registered in the Club Foot Clinic with idiopathic clubfoot of age <2 years and a Pirani score at presentation of more than one were included in the study. Selected patients were randomized in standard and accelerated group by alternate method. Older children, secondary clubfeet, previously operated feet, and feet with local wounds were excluded from the study.

Patients in standard group were treated by weekly plaster changes on outpatient basis. Patients in accelerated group were hospitalized and subjected to plaster changes 3 times a week.

A thorough general examination of the child was done so as to detect any associated congenital anomalies. A complete clinical assessment of all feet made precast and postcast. Parents were educated about the precautions to be observed for children with casts. The aim of treatment was to achieve a functional, pliable, painless, and cosmetically acceptable looking foot. During the entire period of treatment, we try to educate and counsel the parents about clubfoot, importance of early treatment, and bringing the child regularly for follow-up.

We used Pirani score proposed by Dr. Shafique Pirani, Clubfoot Clinic of Royal Columbian Hospital, Canada, for the assessment of initial severity and progress of treatment. This score is easily done at presentation and at each plaster change and has shown good interobserver variability. The score is based on observation of six parameters each having score 0, 0.5, or 1. A child's total score can be between 0 and 6.

Pirani score at final follow-up was used to assess the success of treatment in both groups with results being graded as excellent (Pirani score <1), good (score 1–2), and poor (score >2).

The Achilles tenotomy is an integral part of Ponseti management of clubfoot. Tenotomy is necessary because the Achilles tendon, unlike the ligaments of the foot, is made up of thick, nonstretchable fibers.[7] Tenotomy was done when score for the lateral head of talus became 0 and foot abducted 60°–70°. Final cast after tenotomy was kept for 3 weeks, and after that, Steinbeck-type foot abduction brace was given. For unilateral cases, the brace was set at 60°–70° of external rotation and 30°–40° of external rotation on the normal side. In bilateral cases, it was set at 70° of external rotation on each side. These children were followed up at 2 weeks to troubleshoot compliance issues, every month till 3 months and then every 3 months till maximum possible time, but not <6 months.

Results

A total of 31 children (40 feet) with idiopathic clubfoot were included in the study, nine of whom were bilateral. Of these 31 patients, 19 were male and (57.69%) and 12 female (42.30%). The mean age of the children was 2.7 months in accelerated group and 4.71 months in standard group. A total of 20 feet in each group were included by alternate randomization. There were no significant differences between the groups before treatment and no significant difference in the final Pirani score. Two patients in the accelerated group did not continue with the full treatment and were lost to follow-up.

Initial Pirani score was 5.35 in accelerated group and 4.6 in standard group. Postcast Pirani score was 0.5 in accelerated group and 0.525 in standard group. Mean duration of treatment from the first cast to tenotomy in accelerated group was 18.45 days and in standard group was 47.25 days. Patients not needing tenotomy were provided foot abduction brace at this time. In our study, accelerated group patients needed seven plasters per foot for correction and standard group 6.35 plasters per foot. Tendoachilles percutaneous tenotomy was required in 65% feet in accelerated group and 55% in standard group. Rate of tenotomy was slightly higher among accelerated group. Higher pretreatment Pirani score in accelerated group could have accounted for more rate of tenotomy in this group [Table 1].

Evaluation of deformity and subsequent correction was done using Pirani score. Score was done before initiation of casting, at each plaster change, before giving abduction brace and at follow-up of 3 months. The results were graded as excellent if Pirani score reduced to below 1, good if score was between 1 and 2, and poor if score was >2 at the final follow-up. Accelerated group had excellent results in 16 patients and good results in four patients. In the standard group, excellent results were observed in 15 patients and good in five patients [Table 2].

The Ponseti method, which emphasizes manipulation of the foot with serial casting and tenotomy of the tendo Achillis, is currently the method of choice for conservative treatment of clubfoot as has already been proven by many studies.[11] The conventional Ponseti method involves serial plaster changes at weekly intervals. In a country like India where parents have to travel long distances to bring their children for corrective casting, there are several financial and social issues.[12] Many of these children are not able to complete their treatment and are lost to follow-up which is one of the most important reasons for failure of treatment. Few previous studies have evaluated corrective casting two or three times a week instead of once a week with the patient admitted in the hospital.[9] This method has obvious advantages such as the parents do not need to travel again and again, complete treatment is observed in the hospital which helps detect any issues early, and the overall treatment duration is shortened. With this background, we conducted this study to compare the outcomes of accelerated Ponseti method with the standard method.

Morcuende et al.[13] presented one of the earliest reviews on accelerated Ponseti. They retrospectively reviewed 230 patients (319 clubfeet) retrospectively. They compared 5 days casting with 7 days casting and concluded that both groups had comparable outcomes.

Ullah et al.[14] studied 28 patients in two groups and compared biweekly with weekly casting. In their study, male patients were 16 (57%) and females 12 (43%). Unilateral involvement was seen in 16 cases (57%) and bilateral in 12 (43%). Median Pirani score in their study was 5.2 which improved to below 1 in 85% feet. Tenotomy was required in 80% feet.

Sharma et al.[10] also did a similar study comparing biweekly and weekly plaster change in 40 cases (53 feet). Average duration of treatment in accelerated group was 15 days and standard group was 35 days. They concluded both protocols to be equally effective.

Harnett et al.[9] accelerated the plaster change to 3 times a week and compared it to weekly plaster change. Their study included 40 patients (61 feet). Initial median Pirani score in accelerated group was 5.5 and standard group was 5. Pirani score decreased by average 4.5 in accelerated group and 4 in control group. The authors concluded that triweekly plaster change was equally effective as weekly plaster change and had definite advantages.

In our study, average age of patients at presentation in accelerated group was 2.70 months and in standard group was 4.71 months. Right feet were involved in 22 (55%) patients with male predominance, (57.69%). Average number of casts needed for correction in accelerated group were 7 (14 patients, 20 feet) and in standard group were 6.35 (12 patients, 20 feet). Therefore, the number of corrective casts required for achieving good correction was less in accelerated group and for patients presenting early. As the average duration required for treatment via accelerated protocol was less, we achieved mean follow-up of 7.84 months as compared to standard group where mean follow-up was 6.66 months. Tendoachilles percutaneous tenotomy was required in 65% feet in accelerated group and 55% in standard group, showing that rate of tenotomy was slightly higher among accelerated group. This characteristic was identified by Scher et al.,[7] who related higher Pirani scores to the need for a tenotomy.

Limitations of our study were limited number of patients and short duration of follow-up. We conclude that both accelerated and standard ponseti method are equally efficacious for correction of clubfoot. Accelerated method shortens the overall treatment duration and has obvious advantages[15] as the entire treatment can be supervised in the hospital preventing parents from travelling long distances to bring their children to hospital for recurrent plaster changes. As the patient is in the hospital for entire treatment duration any complications can be detected early.